Covid-19 Infection Induced Pseudo Chilblains

Sinha R and Bansal V

Published on: 2021-07-30

Abstract

Background: The ongoing pandemic due to coronavirus disease 2019 (COVID-19) has been associated with a new constellation of cutaneous features in children, amongst them being pseudo chilblains or covid toes

Case Presentation: 15 yr old boy presented with painful swelling of toes of both lower limbs for last 7 days which was associated with increased sensitivity to temperature change and colour change (initially violaceous to dark black) along with intense itching. There was history of mild COVID 19 infection (RT PCR positive) around 3 weeks back which was managed at home with antipyretics. There was substantial increased inflammatory markers along with marked increase in SARS COV-2 spike antibodies and he was given steroids for 2 weeks along with analgesics following which he showed improvement after 7 days.

Conclusion: This report highlights the rare cutaneous manifestation of COVID 19 infection in children which the clinician should be aware in this ongoing pandemic.

Keywords

COVID 19; Psuedo chilblains; Covid toes; Spike antibodies

Introduction

The ongoing pandemic due to coronavirus disease 2019 (COVID-19) has been associated with a new constellation of cutaneous features in children, amongst them being pseudo chillblains or covid toes [1]. This is inflammatory maculopapular erythematous lesions of the feet and toes, sometimes involving the hands and fingers which mimic acral pernio just like chilblains.

Case Details

15 yr old boy presented with painful swelling of toes of both lower limbs for last 7 days. It was associated with increased sensitivity to temperature change and colour change (initially violaceous to dark black) along with intense itching. There was history of mild COVID 19 infection (RT PCR positive) around 3 weeks back which was managed at home with antipyretics. The examination revealed well child with normal vital parameters with all peripheral pulses well felt and systemic examination was unremarkable. The local examination of the feet revealed violaceous to blackish colour change of all toes with crusting noted over right great toe with tenderness and increased temperature with painful movements at proximal interphalageal joints (Figure 1).

Figure 1:  depicts violaceous to blackish colour change of all toes with crusting noted over right great toe.

The investigation revealed normal complete blood count, renal function test, and liver function test. The inflammatory markers C- reactive protein- 20.8mg/l (0-5), procalcitonin–10.8ng/ml (<0.5), serum ferritin – 512.8ng/ml (8-350), D-dimer- 310ng/ml (<500), Fibrinogen – 512mg/dl (200-400), PT INR 1.07, COVID 19 RT PCR- neg,  SARS COV-2 spike antibodies 131.10 u/ml (<0.8). The child was started on oral steroids for 10 days followed followed by tapering over 5 days and analgesics. The child showed improvement after 7 days (Figure 2).

Figure 2: Depicts improvement after 7 days.

Discussion

It appears that the pseudo chilblain-like lesions related COVID-19 pandemic may reflect a brisk immune response depicting good prognosis mostly due to robust innate immunity. The possible need to screen for coagulopathy is unclear, but this is generally suggested due to treatment implications. The exact pathophysiology of pseudo chilblains in poorly understood but few studies have found some linkage to COVID-19 through the serum IgA or IgG severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein which was present in our case too. In pediatric cohort COVID toes, it is mostly associated with aymptomatic COVID infection compared to adults [2]. It appears that the chilblain-like lesions related to the period of the COVID-19 pandemic may reflect a brisk immune response predicting a good prognosis and perhaps some form of innate immunity [3,4].

Conclusion

This report highlights the rare cutaneous manifestation of COVID 19 infection in children which the clinician should be aware in this ongoing pandemic.

References